Dr. Baile: Hi, I'm Dr. Walter Bale, professor of behavioral science and director of the MD Anderson Cancer Center Program on Interpersonal Skills and Relationship Enhancement or I*CARE. We're very pleased today to welcome for our ACE lecture interview Professor Massimo Biondi. Professor Biondi is head of the Department of Psychiatric Sciences and Psychological Medicine at the University Sapienza of Rome. Since 2007 he's also been director of the School of Psychiatric Specialization at the same university. Professor Biondi is the author of 4 and editor of 12 books and over 300 scientific publications about 70 of which are in English in international journals. He's the editor also of a number of other scientific publications and a member of the Advisory Board of the American Psychiatric Publishing Textbook of Psychiatry 5th edition. Professor Biondi's main interests are diagnosis and treatment of anxiety and mood disorders but also psychosomatic medicine. And within psychosomatic medicine many of his studies concern stress, psychoneuroendocrine and immune related changes. He's extended this research more recently to include the psychosomatic aspects of provider, patient communication which we'll be talking about with him today. So Massimo, thank you very much for coming and giving our lecture and agreeing to have a talk with us.

Dr. Biondi: Thank you to MD Anderson for the invitation.

Dr. Baile: So, you're a psychiatrist, how many years have you been a psychiatrist?

Dr. Biondi: I was interested in psychiatry since I was a medical student, more than 30 years ago. I remember it was an exciting period and from the study of the brain and of the mind I remember how much new discoveries were done. So, I was really excited about that.

Dr. Baile: Yes. And so in addition to some of the traditional psychiatric disorders that you've been involved with such as mood disorders and psychosis, things of that sort. That explains a bit how you got interested in psychosomatic medicine and psychoneuroendocrine disorders. Tell us more about that.

Dr. Biondi: It began in a clinical setting, talking with patients trying to understand how their life stress events they were recollecting can really affect their diseases, the process of diseases. May be sometimes also it's your pathogenesis. It was a mystery because we had only psychological explanation which were telling about nothing, about what really happened in the body.

Dr. Baile: The body.

Dr. Biondi: So, the study of the mechanisms, for me it was crucial to understand how psychological processes and reactions to events of life could affect the process of bodily diseases. And so the next step was to study the autonomic nervous system, the psychoneuroendocrine systems then the immune system.

Dr. Baile: So, that must have been quite a challenge about how to do that and I wonder if you could tell us how you began to investigate some of the relationships between your patients' and other patients' life stresses and what changes happen to the body by way of the nervous system.

Dr. Biondi: I remember that we began together with Professor Paolo Pancheri in Rome to study the amount of life stress. I remember that many research was done in the United States by [inaudible] and other authors such as [inaudible] at the University of Seattle. We are in touch with them but after assessing life events we need to study what the events can do in the physiology of the organism. In those years, early '80s we had the discovery of the endorphins and so very many others, peptides and neuropeptides. So, we studied the effects of--the behavioral effects of peptides and we were--we're believing that we have the link between the mind and the body in peptides. Then we have the role of cytokines and so on. Every time we are studying how life events and stress events or stress stimuli could modify such mediators in the body and especially we were interested in assessing how different coping styles or personality traits can modify the responses. That is you can have more anxiety, more demoralization and you can have also different coping resources that is an avoidance style or a confronting style and so on. So, we understood that when a person is suffering without the ability to cope effectively or is suffering in silence psychosomatic disorders are easily in the way to be activated. That is the risk is more and more--seen also in many experimental studies on animals up to some cases of cancer, yes.

Dr. Baile: Now, I know that there--I mean it's very clear how this beautiful progression of scientific studies beginning with learning how to assess life stress then learning how to assess the relationship of life stress to neuroendocrine immune changes and then relating that to disorders and how they are modified by patient coping was a beautiful sort of logical progression of research. So, can you tell us a little bit about--you used the term psychosomatic disorders and I wonder kind of what you were thinking of or when you kind of said that life stress can lead to brain changes which can lead to psychosomatic disorders. What kind of things were--

Dr. Biondi: As a starting point we were based on the study of Franz Alexander in Chicago in the early '40s and we had the 7 holy diseases as psychosomatic disorders. Year by year many scientists were convinced that you had any disease as a potential psychosomatic disease and the question is not if--is a disease or disorder is psychosomatic or not. The question is if at what extent psychosocial stimuli has a role in the pathogenesis or in the cause. So, you can have [inaudible] patients without no evidence of psychosocial or emotional stresses because there is a lot of pathophysiology. Another patient [inaudible], another patient again can have an ache or some pain disorder strongly influenced from psychosocial stimuli and stresses of his life. This is true for myocardial infarction, essential hypertension, many immune-inflammatory diseases. So, time by time we need to assess patient by patient which is the role of behavioral factors and psychosocial stimuli in his or her diseases. That's the way. Then we need to study and verify which are the mechanisms involved. So to find the therapy and which kind of therapy can interfere or prevent by working at such a level of mechanisms.

Dr. Baile: Now, I understand that there are some ways of studying these mechanisms and these relationships and can you talk a little bit about some of the more recent studies on brain fMRI and some of the discoveries that have been made which help clarify some of those links.

Dr. Biondi: Yes, it's--I think we are living a very exciting period of research because the boundaries between the brain and the body, between the brain and the mind are vanishing. That is in many cases you have also the boundaries between psychiatric disorders and psychosomatic or bodily disorders because at any time you have changes in the brain after events or thoughts.

These are changes that are linked to a chemistry of the brain so psychological explanation or biological explanations are only method of words. Study with the functional resonance have shown--have clearly shown that while we are--we have a thought, we are angry, we are happy, we have several changes in many pathways in the brain. We have specific circuits which are involved in angriness, happiness, in talking in--so it's our language which is prone to represent as a psychological or biological or chemical. When we are happy or we are think of something--or we are doing of who can add to us wellbeing we are probably stimulating our dopamine and serotonin in the brain. That is that some behaviors can change and modulate our chemistry in the brain while serotonin, dopamine noradrenaline can be changed by the seasons or by what we eat and so on and affect what we thought and what we feel. This is--I mean, a continuous interplay and so what we see also when we have a communication between a patient, provider and the patient. They are--their chemistry communicating and what I say what the patient says to me makes changes in my brain, my amygdala if I had some feeling of fear or other centers, pathways if I am really caring for him. So it's a completely new way to see also the interaction between the provider and the patient.

Dr. Baile: So I know that fMRI is a very sophisticated and expensive way of studying some of these changes but you've kind of--you've done some work on being able to find some other more direct and more simple ways of measuring that and using some of the instruments could you say anything about that?

Dr. Biondi: Yeah so I'm--I was impressed by the simplicity of oldest methods of recording our psychophysiology. They were popular in the '60s and '70s and they are easy to do simple, reliable, very precise and the in a setting like this one. They are not invasive. I can record what you're feelings are and mine just putting some sensors here. And you have a minute by minute recording of what happens to my emotional arousal which is linked to my brain activity. It's like a window into the brain. It's linked to the cholenergic activity of the--my sweating glands and so it is pretty precise. So you can study what happens to me and to you for half of an hour without being invasive, without neither or nothing. And what is also important without expenses.

Dr. Baile: So tell me what you have found in stressful communications--

Dr. Biondi: Interactions.

Dr. Baile: Between provider and patient? What kind of changes have you seen in some of these measurements?

Dr. Biondi: Changes of--temporary changes of heart rate. In general with an increase up to 10 or 15 beats per minute. You can also see the electromyographic changes--

Dr. Baile: Muscle?

Dr. Biondi: Ah, muscles, everywhere in the frontal level and the forearm or where ever you want, changes in the GSR that is the sweating of the hands. They are very little. Maybe we are unable to look at them but--with our eyes but we can record with the instruments then also with temperature, skin temperature which is related to peripheral vasoconstriction. Both of them are linked to the autonomic nervous system and to some extend to the psychoneuroendocrine system. And they change during a conversation according to the issues, according to the emotion which are linked to the issues both in the provider and the patient.

Dr. Baile: So it's very interesting because I remember a study done a few years ago that had shown that the incidence of hypertension in women has gone up significantly over the past 10 years.

Dr. Biondi: Yes.

Dr. Baile: And so it makes people wonder whether or not women entering into the work force undergoing the stress of pressure of job pressures have been related to this increase of blood pressure. And I'm wondering if there is any data or where we're at right now in terms of research in discovering the long term consequences of the changes that you've noted with regard to galvanic skin response, high blood pressure and the brain changes that have been shown in people undergoing stress. Do you think we're anywhere near explaining chronic disease on the basis of this?

Dr. Biondi: It's an interesting idea. We can gather data from epidemiology from the changing profile of diseases in Western countries which become more chronic and long lasting then if your data on personality and coping styles. Maybe relevant is also the social support available which is a protective factor. Then there are factors related to the individual vulnerability that is which disease are you prone to have? It depends also on this lifestyle, what you eat, what you do. So it could be that some people who are prone to hypertension but live in a quiet way without pressure they never get the protection while--if those people are put in a office or in a busy area everyday criticized, competing and so on. Maybe their adrenergic system according to what their brain suggests, they are tense, angry, it is rare [inaudible] if they can actively confront and cope well with the stimuli or not. If they can feel themselves efficient in response or not and so on, then the probability of development of hypertension in women could be also related to some of these behavioral factors.

Dr. Baile: That's very, very interesting. Let me turn attention for a few minutes to the whole world of cancer care. And, you know, my interest is in giving bad news and some of the other stressful interactions that cancer providers have with patients and families. You know families are under a lot of stress. They--sometimes they get upset, sometimes they're unhappy with their care and I wonder if we have any window on what that does to the provider and in terms of what do you think can happen to people when they're--have what we called caregiver fatigue or caregiver burnout and could you say something about that?

Dr. Biondi: I have only anecdotal data but I have seen that when one is speaking with a person with cancer especially there is a method of bad news. Everyone, not only the patient, is suffering. For a provider to speak with a patient is a very difficult painful experience. So giving bad news, talking about bad news just within the family to speak about a recent diagnosis is a painful experience. This is the main reason why I believe in many countries and also now in the United States many people, providers also have a distant disposition. They avoid to communicate because emotions elicit pain that's the main problem.

And in many cases we are not trained to speak, to sustain, to understand, to say yes it's true, now what get can I do, how can I help you? And the only way is to avoid , silence.

Dr. Baile: Does avoidance work as a coping strategy?

Dr. Biondi: To some extent, yes. But in--just in a moment.

Dr. Baile: And then if patients are not told the truth and conversation is avoided then they're unhappy with the information given.

Dr. Biondi: And pain remains because the thoughts remains there in the mind of the provider like they remain on the family member like in the patient [inaudible] that is not elaborated and already doing the worst thing that they can that is destroying faith and unexpressed--

Dr. Baile: Trust.

Dr. Biondi: Yes.

Dr. Baile: So this idea that you can avoid stress by not talking to patients about bad news or giving them incomplete information it is not so true because the idea in your head that you should have done it and questioning whether you should have done it is equally as stressful as going through the conversation. That's a very, very interesting thought.

Dr. Biondi: Yes, yes.

Dr. Baile: So for providers for example who decide not to avoid. What should they do? How can--what is the best way for them to both maybe avoid the stresses of the moment and to avoid the long term stress that might come along with being a cancer caregiver or a cancer provider. Do you have any thoughts about that?

Dr. Biondi: First careful training about communication, about what happens within you, what to say when, when to speak to a patient first. Secondly, to be actively positive in your life that is have many areas of restore, leave your mind collect positive experiences which are counter balancing pain. So pain is unavoidable to some extent.

Dr. Baile: You--the pain in the sense of distress?

Dr. Biondi: Yes. Stress also is inevitable especially in some diseases and some situation. But we can learn to handle it. We can reinforce social support. We can be able to speak about it not to. And we can make several choices to recharge and restore us.

Dr. Baile: For recharging our own batteries so to speak?

Dr. Biondi: Yes, yes.

Dr. Baile: So you would recommend people going on vacation for example?

Dr. Biondi: Maybe I suggest Maldives but--

Dr. Baile: The Maldives okay well [laughter].

Dr. Biondi: There are many places in the world to go.

Dr. Baile: Yes, yes for anyone who hasn't been to the Maldives you can watch Dr.--Professor Biondi's presentation and see some--see some photos. So this idea of this two-pronged approach to dealing with provider stress both teaching them how to communicate effectively, how to handle their own emotions, how to be a support to the patient after giving bad news plus avoiding burnout by making sure that there are positive things in your life seems to be a very good prescription for people who are dealing with cancer patients and cancer families and other people.

Dr. Biondi: Okay.

Dr. Baile: Well thank you, very, very much. Today we've been visiting with Professor Massimo Biondi from the University of Rome and for those of you who want to get a more in depth glimpse of some of the issues that he has been talking about today. You can go on to our I*CARE website and see his complete presentation at our Achieving Communication Excellence (ACE) Lecture. Thank you Massimo.